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APPLICATION FOR WELLIPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION RO, BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 (209) 469.3410 MON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete In Triplicate) APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WRIT SAN JOAOUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY P,UI331-IC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. �) JOB ADDRESS/OR APNI 4-131S i41�(,-f1J`� �U��', 5l�' L.<<f� S� CIT( 7 �a,f-jlEp, 7 PARCEL SIZE/APN# / J /�G.' -eJ,�• OWNER'S NAME `!��i OiN:/TiS f-U•(1� ADDRESS_ PHONE# r CONTRACTOR /�[=%jJr— ^(�•'I ADDRESS UCI PHONE I SUR CONTRACTOR ��=�J,i��l"7 �d%�Di2iQtir•>r'1 r ADDRESS UCI PHONE+► TYPE OF WELL/PUMP: ❑ NEW WELL ❑ REPLACFMENT WELL ❑ MONITORING WFLL# ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# R VPE OF PI/MP) 11New 13Reneir H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O ��yy 11F OUT-OSERVICE WELL ❑ GEOPHYSICAL WELL# lid SOIL BORING B 'LY DESTRUCTION: //LL/y%1T (/1'"�G✓'/ / INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS --- A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO p ❑ DOMESTIC/PRIVATF ❑GRAVEL PACK/SIZE TYPE OF CASINO/STEEL/PVC DIA.OF WELL CASING D ❑ r'UBUC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R ❑ IRRIGATIONIAO ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E ❑ MONITORING GROUT SEAL PUMPED: [1Y- ❑No CONCRETE PEDESTAL BY DRILLER:❑Y- ❑No S APPROX.DEPTH / LOCKING CHESTER BOX/STOVE PIPE S. PROPOSED CONSTRUCTION/DRILUNO METHOD: MUD ROTARY r,J AIR ROTARY AUGER CABLE OTHER 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WIT"SAN JOAOUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND RFGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY FERRO NS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN TIIE PERFORMANCE OF THE WORK FOR WHICH THIS PFRMrr IS ISSUED,1 SHALL EMPLOY PERSONS 911PJFCT TO WORKMAN'*COMPENSATION LAWS OF CALIFORNIA." THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 12001460-3423. COMPLETE ORAWING AT LOWER AREA PROVIDED. BlOn"d X_._ (.,,,j-- Title Drat" •� PLOT PLAN ID—to 9eN"I Sr..l" 'to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SFWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTLINFS AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SUCK AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. DEPARTMENT USE ONLY /^ / Appllc"Ilan Aeeepterl By. (�_�_ D"te `Z��1CJ—�yv A— Growl Imp"c Llan BY Pump Inepeetlen By Det" Dmtnretlon In�perlbn RY D"te Cemmonb: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INTO MM"DATEPERMIT/SERVICE REQUEST NUMBER INVOICE Pub.Health Serv.-Enviro.173(3/96)